Is there more than one way to push during labor?

Yes. There are two very different ways to push, or bear down to help move your baby move through the birth canal during the second stage of labor.

One widely practiced method is called coached pushing, or directed pushing. With this type, a labor support person (often a nurse) directs you to begin pushing as soon as you're fully dilated to 10 centimeters, even if you don't feel an urge to bear down. You may also be instructed how to push.

The other approach is known as spontaneous pushing. In this method, you follow your body's natural urges, pushing when you feel ready, and in whatever way feels right to you.

Midwives often favor spontaneous pushing, while coached pushing has long been routine in most U.S. hospitals. However, research suggests that the practice often has no advantages for you or your baby – and may even have some disadvantages for both.

The American College of Obstetricians and Gynecologists (ACOG) now recommends that women be encouraged to use whichever pushing technique is most effective for them.

The organization also suggests resting for an hour or two at the beginning of the second stage of labor (unless you have an urge to push sooner), especially if you have an epidural or if this is your first baby. This rest period gives your baby time to descend on his own while you conserve your energy for pushing. The pushing stage goes until just before the baby is born, and it can last from a few minutes to several hours.

How is coached pushing done?

Coached pushing can begin as soon as your cervix has dilated completely to 10 centimeters, which marks the beginning of the second stage of labor.

In most cases, a labor and delivery nurse leads the coaching. Typically, you're told to take a deep breath at the beginning of every contraction, hold it, then tighten your abdominal muscles and push down with as much pressure as possible while the nurse counts to 10. (Some moms say it feels like straining to have a bowel movement.)

Then you take a quick breath and push for another count of 10, aiming to get in three pushes during each contraction.

To avoid tearing, you may be told to stop pushing when your baby is crowning – that's when the widest part of the baby's head is passing through your vagina.

How does spontaneous pushing differ from coached pushing?

In spontaneous pushing (also known as physiological or mother-led pushing), you follow your body's natural urge to push.

Women doing spontaneous pushing tend not to take a deep breath beforehand, and they exhale while pushing instead of holding their breath. The role of the labor support person is to remind you to listen to your body and encourage you to bear down whenever and however it feels right to you.

You may feel an uncontrollable urge to push as soon as you're fully dilated, but many women don't – particularly those who have an epidural. If you don't have an urge to bear down at this point, you can rest while the baby continues to descend from the force of your contractions alone. (This is sometimes referred to as laboring down.)

If you have an epidural, you may feel an urge to push when the baby gets low enough, although it's possible to have an epidural so strong that you never feel this urge. (Even if you can't feel the sensation to start pushing on your own, your labor support person can guide you.) In some cases, your provider may let the epidural start to wear off when it's almost time to push.

Once you start feeling the urge, you may push for just a few seconds during the peak of the contractions at first, and not during every contraction. Women who aren't being coached generally let a contraction build before bearing down. Also, spontaneous pushes tend to be in shorter but more frequent bursts during contractions.

As the baby descends and puts increasing pressure on your pelvic floor (the muscles and other tissue that support the uterus, vagina, bladder, and rectum), you may begin to push harder and more often during contractions. You may also grunt, groan, or make other noises when pushing.

Why is coached pushing done?

It's not clear why coached pushing became a routine practice in U.S. hospitals. Earlier studies suggested that a prolonged second stage was riskier for the baby, so the practice of coached pushing may have come about as an effort to shorten this stage.

However, by the late 1970s, new research suggested that as long as monitoring showed the baby was tolerating labor well, a long second stage of labor didn't necessarily affect the baby's health, and some experts began to question the value of routine coached pushing.

Coached pushing may still be beneficial in some cases. For example, if you don't feel the urge to push, you may eventually need some guidance to help you push effectively.

Coaching may also be appropriate if you're so fearful or tense during labor that you have trouble listening to your body's cues, or if you're too afraid to push because you don't like the sensation. Some women ask for specific directions.

What are the advantages and disadvantages of coached pushing?

A 2017 review of eight studies comparing coached and spontaneous pushing found no significant differences in outcomes between the two methods. Researchers recommended letting the mother choose to push as she wishes.

However, other studies have found that coached pushing as it's typically practiced was associated with one or more of the following:

Many midwives point out that coached pushing dismisses a woman's instinctual knowledge of when and how to push, and limits her ability to give birth in a gentle manner.

How should I handle pushing?

Many experts now believe that coached pushing may help in some cases, but it shouldn't be a routine practice. ACOG and other organizations are in favor of mothers letting their bodies tell them how and when to push.

In most situations, it's preferable to wait until you feel the urge to push, whether or not you have an epidural. If you have an epidural but no urge to push, you may want to wait an hour or two after you're fully dilated or until your baby's head is very low in your pelvis before beginning to push.

Rice Simpson K. 2006. When and how to push: Providing the most current information about second-stage labor to women during childbirth education. Journal of Perinatal Education 15(4):6-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804305/ [Accessed September 2017]

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